Failure to Complete Timely and Accurate Transfer/Discharge Documentation for a Resident Sent to Hospital
Penalty
Summary
The deficiency involves the facility’s failure to ensure complete, accurate, and timely transfer/discharge documentation for a cognitively impaired resident who was sent to the hospital for stroke-like symptoms. The resident was an elderly female with multiple diagnoses, including depressive episodes, GERD, anemia, insomnia, hyperkalemia, and diaphragmatic hernia, and had dementia with impaired cognition (BIMS score of 4), communication problems, unclear speech, ADL self-care deficits, and limited mobility. The resident’s face sheet showed no discharge date, and her care plan and MDS confirmed significant cognitive and functional impairments. According to family and staff interviews, an LVN observed stroke-like symptoms and ultimately called 911 to transfer the resident to the hospital, reporting that the resident had shown such symptoms for approximately 24 hours without the family being notified. Family reported they did not receive an official call from the facility about the change in condition or transfer, and no one from the facility contacted them to check on the resident’s status after the transfer. The attending physician later stated that she had been called by the LVN and had directed an immediate transfer to the hospital due to stroke-like symptoms. Multiple staff, including the HS, LVN C, the Med Aid, the interim DON, and the ADM, confirmed that the responsible nurse (LVN A) did not complete required documentation related to the resident’s change in condition and discharge. Specifically, there was no SBAR, no change-of-condition note, and no discharge summary completed at the time of transfer, and the resident’s clinical record contained no notes reflecting physician and family contacts, the reason for transfer, or how and when the resident left the facility. The interim DON and ADM stated that the missing SBAR prevented the discharge summary from being triggered and kept the discharge from appearing on the ADT report within 24 hours. The discharge summary was only completed later by the interim DON after surveyor intervention, confirming that the facility failed to ensure timely and accurate transfer/discharge documentation to support continuity of care.
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